Foreign Medical Graduates Are Major Crutch for VA System

Dr. Raymond Osarogiagbon had planned to return home to Nigeria after he completed medical studies in the United States. But the VA hospital in Amarillo needed a hematologist-oncologist, and he decided to stay in this country. Forty percent of the Amarillo VA hospital's doctors are foreign-born. (Photo by Scott Shaw)

Foreign Medical Graduates Are Major Crutch for VA System

By JOAN MAZZOLINI

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Veterans hospitals have hired thousands of foreign doctors, at times passing over qualified Americans in the process.

VA hospitals must justify hiring foreign doctors by showing the need is so great that a medical service would be severely affected or even stopped were they not employed. But many were hired in part-time positions, a Plain Dealer review of VA hiring practices found.

The VA says the U.S. Immigration and Naturalization Service endorsed those part-time hires, even though immigration laws allow foreigners to stay only for full-time jobs. INS officials said they weren't aware that foreign doctors were being hired for part-time VA positions.

VA officials, who would answer questions only in writing, said that because U.S. doctors often look for more lucrative jobs, hiring foreign doctors "allows (the) VA to hire exceptionally well-qualified physicians who otherwise would not be available to care for veterans."

But critics say veterans hospitals don't always make the effort to find U.S. doctors, instead hiring foreign doctors who line up for VA jobs, in some cases just to legally stay in the United States.

About 1,000 doctors out of 12,000 working at veterans hospitals are graduates of foreign medical schools, VA officials said. A small percentage could be Americans who attended foreign medical schools.

While many are excellent doctors, others have questionable medical educations. Also, critics say some of them can't communicate well with their patients because of language and cultural differences.

"It's a sensitive issue from a number of perspectives," said Dr. Kenneth Kizer, former VA undersecretary for health. The need to hire these doctors has diminished, he said, because "the VA really doesn't have very much trouble hiring (U.S.) physicians today."

Using the records and physician staff lists from the 172 veterans hospitals, The Plain Dealer determined whether their employment was full or part time.

Twenty percent or more of part-time doctors at the Cleveland, Little Rock, Ark., Pittsburgh and Syracuse, N.Y., veterans hospitals, for example, were foreign medical graduates. The hospitals had all made requests in 1999 to hire foreign doctors.

Foreign medical graduates at the Gainesville, Fla., St. Louis, West Haven, Conn., and Cincinnati VA hospitals make up about 15 percent of their part-time staffs. These hospitals also had requested to hire foreign doctors in 1999.

The Salt Lake City veterans hospital requested in 1999 to hire Dr. ********an Beddhu, who had graduated in 1989 from an Indian medical school. VA headquarters turned down the initial request, which was not for a full-time job.

"Make sure they understand that this must be a full-time position (which would include an appointment at University of Utah)," the log states. "Director's letter needs to reflect FT (full time) offer."

A reconsideration was approved by headquarters. Beddhu was hired for a 30-hour-a-week job at the Salt Lake City VA.

Most of the VA's part-time doctors spend the rest of their work week at the better-paying affiliated medical schools and university hospitals.

The documents showed that at least three veterans hospitals -- Syracuse, Little Rock and West Haven -- hired foreigners in 1999 even though Americans applied, and despite immigration rules and VA policy prohibiting those hires. VA officials said they couldn't comment on specific hires because that would invade the privacy of the doctors.

The West Haven hospital's request in June 1999 caught the eye of a top VA official who was "concerned about the number of citizens available and the reasons for not selecting them," according to VA documents.

Even so, VA headquarters approved West Haven's request to hire Dr. Rajaa Chatila, who graduated in 1990 from a medical school in Lebanon.

A nearly identical situation occurred the year before when the Philadelphia hospital asked to hire Dr. Nayyar Iqbal, who had graduated in 1990 from a medical school in Pakistan.

VA headquarters first denied the request "due to number of qualified citizens" who applied but were denied. And officials said they would "request an informal review ... concerning the number of permanent resident or citizens (nine) that applied and was found unacceptable."

But the Philadelphia hospital asked VA headquarters to reconsider. In early 1999, it got the OK to hire Iqbal.

The seven years of VA "logs" detail more instances where VA officials noted that foreigners were hired over U.S. applicants. And in some cases, they show that not every veterans hospital tries to find American doctors before hiring foreigners.

In cases where VA headquarters approve the hire, the request is sent to the U.S. State Department and then to INS. Neither agency has ever rejected a VA hire.

VA officials say they hire highly qualified doctors. And they said the documents obtained by the newspaper are incomplete.

"These logs do not contain all of the details regarding individual applicants," the VA wrote. "A VA facility may submit additional supporting documentation with their request for reconsideration."

INS officials questioned the process.

"If they're using excuses that there's a shortage of eligible workers as justification for hiring (foreigners), that's wrong," said Bill Strassberger, INS public affairs officer. "Flat out, that's wrong, that shouldn't be happening.

"We don't want to see eligible (U.S.) workers, including doctors, being denied an opportunity."

However, Strassberger said it's unlikely that the INS would take any action against the VA. His agency has more pressing concerns.

Foreign medical graduates fill a big hole at U.S. teaching hospitals. About 16,000 people graduate from U.S. medical schools each year, but there are 22,000 residency slots at the teaching hospitals.

Graduates of foreign medical schools are recruited to fill those 6,000 extra slots. Once the foreign students finish their residency training, U.S. immigration laws require they go home for two years before trying to return.

"Once they've been here ... it's like, `Wait a second, now it's time to get on the gravy train,"' Strassberger said.

And snagging a full-time position at a veterans hospital or a job in areas with few doctors gets them a waiver of the two-year home rule.

Until 1996, foreign doctors had to agree to work just a year at the VA for the waiver. That went to three years and last year increased to a five-year commitment for jobs at the VA or in an underserved area.

Dr. Fitzhugh Mullan, former assistant surgeon general in the U.S. Public Health Service, has been a longtime critic of importing foreign medical school graduates. The practice has been "corrupted" over the years, he said.

"People use it unabashedly as a route into the United States," said Mullan, who wants American medical schools simply to produce more doctors.

"Nowhere do I know of, in industry or education, where we make a policy that 25 percent of the coveted positions ought to be reserved for foreigners," he said.

Kizer, the former VA undersecretary, noted that "with changes in the marketplace and all the other things happening in health care, the VA actually has become a pretty desirable place to work. But there are certainly some parts of the country, it doesn't matter if you're VA or private, it's hard to recruit U.S.-trained physicians."

And foreign doctors like Dr. Raymond Osarogiagbon have filled positions shunned by American doctors.

Osarogiagbon had planned to return home to Nigeria after his residency. "That's why I got into hematology, because sickle-cell diseases are very prevalent diseases there," he said.

He changed his mind and Nigeria's loss was a Texas VA's gain. The VA hospital in Amarillo needed a hematologist-oncologist.

Advertisements in medical journals to work in the Texas Panhandle don't elicit U.S. doctor applicants. Foreign medical graduates like Osarogiagbon make up about 40 percent of the more than 50 members of Amarillo's physician staff, according to VA officials there.

"Without a doubt, obviously those (U.S. doctors) who have a choice are able to stay away from the rural areas," Osarogiagbon said. "I came all the way from Nigeria 10,000 miles away. Why would I now make a distinction between a big city and a small city in the U.S.?"

Many doctors do. And while recruitment for U.S. doctors is easier today, rural areas such as Amarillo or Chillicothe, Ohio, still have tough times bringing U.S. doctors on board.

Psychiatry, which has the largest percentage of doctors in the VA system, is one of the most common specialties foreign medical graduates enter. In veterans hospitals in Detroit, Oklahoma City, and Augusta, Ga., half or more of the psychiatric staffs are foreign medical graduates. And at least four VA hospitals have hired psychiatrists educated in medical schools in Vietnam.

But in psychiatry, common language and culture between the doctor and patient are vital, experts say.

VA officials said that what is most essential is that the veteran have a "skilled and caring physician." And VA officials defended hiring Vietnamese psychiatrists who could be treating Vietnam veterans.

"It could conceivably be advantageous for a Vietnam veteran to be treated by a Vietnamese doctor, who understands and perhaps shared the horror of war and the environment American vets served in," the VA said.

Graduates of foreign medical schools get an unlimited number of chances to pass two medical science-based tests and an English language exam needed to enter a U.S. residency program.

About half of the foreign medical graduates pass the two science tests on the first try, according to the Educational Commission for Foreign Medical Graduates, which administers the test. In comparison, about 90 percent of the graduates of U.S. and Canadian medical schools pass the two tests on their first try.

Those foreigners who choose to try to stay must take a final test administered by state medical boards, like American residents, to be licensed to practice medicine in the United States.

Even after years of advanced training in the United States, foreign medical graduates passed at a lower rate than graduates of U.S. and Canadian medical schools. About 56 percent of foreign medical graduates passed the test on the first try in 1999, in comparison to the 91 percent of U.S. and Canadian medical school graduates.

The General Accounting Office, the investigative arm of Congress, found that it was difficult for state medical boards to determine the quality of foreign medical schools. The investigation focused on U.S. citizens who were attending foreign schools and paying with loans from the U.S. Department of Education.

"Educationally underqualified physicians may be entering the mainstream of American medicine," the GAO report found.

Some foreign doctors struggle with English even though VA officials say they insist that foreigners be proficient in the language. The VA, however, has "accent reduction programs" for some foreign physicians.

During a recent visit to the VA hospital, Brown, who served in the Navy during the Korean War, said she asked the young doctor to repeat herself several times. "She could not speak English well enough."

Brown's feelings are not unique.

"There were times over the years that a patient would have a problem, primarily a Vietnam-era vet would have a hard time relating to someone with an Asian background," said Dr. Steve Cohen, director of the Dayton VA, where more than half of the staff's nearly 90 doctors are foreigners.

Language problems surfaced in a Denver courtroom a few years ago.

In 1995 a federal judge found that the VA botched its care of veteran John Deasy and awarded him $4.5 million. The judge determined that language problems contributed to the bungled treatment.

Deasy was tied down, drugged and locked down over several years' time because of a medical condition that caused psychiatric symptoms. Experts testified that Deasy's fear of maltreatment worsened his psychiatric problems. Federal Judge Jim R. Carrigan agreed.

"Mr. Deasy has been treated by a platoon of VA doctors, each taking his turn for no apparent reason other than the fact that he happened to be on call when this patient needed care," the judge wrote. "Indeed, one of the physicians who treated Mr. Deasy spoke English so poorly when testifying at the trial that both the court and the court reporter repeatedly had to interrupt his testimony to ask that he repeat more clearly what he had said.

"This doctor's heavy accent and submarginal communication skills in court corroborated Mr. Deasy's testimony regarding his frustration when trying to explain that his problems were physical and not just psychiatric."

Moderator - State Licensing Forum

Still skeptical after all these years.
This is it. There are no hidden meanings.WYSIWYG

The entire US medical system has used FMGs, US IMGs as a crutch. The population of the US has grown by 75 million in the last 20yrs and there have been just 2 new US medical schools started. There has been a real lack of investment in this area. Many highly qualified US students go to foreign schools b/c there are not simply enough spots and they have applied multiple times to US schools without luck. The increasingly aging population, as our population demographics are highly skewed towards the elderly and increased medical attention and longer life has created a great need for more health care providers. The need for physicians and the lucrative business of medical education has lead to the abundance of Caribbean schools, as we all know. The US medical schools are supposedly going to try to increase classes by 30% from what I have read. But, if we actually get some kind of health care insurance for the 45million people who don't have it or even 1/2 of those people(realistically) the system is swamped with the current supply of dcotors. So, the US will need alot more FMGs or US IMGs.

the overall tone of the article led me to believe that it was portraying that somehow the FMGs were worse then the qualified US docs, when many times there are great foreign trained docs that are simply better then their US counterparts.

but remember that, even when those who move you be kings or men of power, your soul is in your keeping alone. When you stand before God you cannot say "but I was told by others to do thus" or that "virtue was not convenient at the time." This will not suffice. Remember that.